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ESC HEART FAILURE REVIEW
ESC Heart Failure (2022)
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ehf2.14104

Obesity and contraceptive use: impact on

cardiovascular risk
Giuseppe M.C. Rosano1* , Maria Angeles Rodriguez-Martinez2 , Ilaria Spoletini1
and Pedro Antonio Regidor3
1
Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy; 2Freelance Consultant of Pharmacovigilance and Clinical
Development, Madrid, Spain; and 3Exeltis Healthcare, Ismaning, Germany

Abstract
Obesity and oestrogen containing contraceptive products are well-known independent cardiovascular risk factors. However, a
significant number of obese women continue to receive prescriptions of hormonal products that contain oestrogens for their
contraception. We have conducted a narrative review to discuss the latest evidence, ongoing research, and controversial is-
sues on the synergistic effect of obesity and contraceptive use, in terms of cardiovascular risk. There is compelling evidence
of an interplay between obesity and contraception in increasing cardiovascular risk. Women who present both obesity and
use of combined oral contraceptives (COCs) have a greater risk (between 12 and 24 times) to develop venous thromboembo-
lism than non-obese non-COC users. Data here discussed offer new insights to increase clinicians’ awareness on the cardiovas-
cular risk in the clinical management of obese women. The synergistic effect of obesity and COCs on deep venous thrombosis
risk must be considered when prescribing hormonal contraception. Progestin-only products are a safer alternative to COCs in
patients with overweight or obesity. Obese women taking contraceptives should be viewed as an ‘at risk’ population, and as
such, they should receive advice to change their lifestyle, avoiding other cardiovascular risk factors, as a form of primary pre-
vention. This indication should be extended to young women, as data show that COCs should be avoided in obese women of
any age.

Keywords Obesity; Combined oral contraceptives; Venous thromboembolism; Cardiovascular risk; Deep venous thrombosis
Received: 19 October 2021; Revised: 29 June 2022; Accepted: 28 July 2022
*Correspondence to: Giuseppe M. C. Rosano, Centre for Clinical & Basic Research IRCCS San Raffaele Pisana, via della Pisana, 235, 00163 Rome, Italy. Tel: +39 06 52252409;
Fax: +39 06 52252465. Email: giuseppe.rosano@gmail.com

Introduction In this article, we will discuss the latest evidence, ongoing

Obesity is as a major challenge in cardiovascular patients.
Indeed, adiposity exacerbates cardiac dysfunction along
with hypertrophy, worsens cardiac insulin resistance, and
reduces basal and insulin-stimulated glucose oxidation
rates.1
Contraceptive use is another well-known cardiovascular
risk factor, being associated with increased thrombotic risk.2
As such, both these conditions are conceived as potentially
reversible risk factors. Their effects on cardiovascular out-
comes are increasingly recognized.3
research, and controversial issues on the cardiovascular im-
pact of obesity and contraceptive use, with a specific focus
on clinical implications.
First, we will summarize the role of overweight/obesity as
independent risk factor for thromboembolic events. Second,
we will discuss the data on contraceptive use as independent
risk factor for venous and arterial thromboembolic events.
Third, we will summarize the available evidence on the
interplay between the two factors, examining data on throm-
boembolic risk and contraceptive use in obese women. Finally,
current clinical recommendations will be discussed.

© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
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2 G.M.C. Rosano et al.

Obesity in women of reproductive age:
an independent risk factor for venous
and arterial thromboembolic events
Venous thromboembolism (VTE), myocardial infarction (MI),
and stroke are the most common cardiovascular diseases.
VTE is the formation of a blood clot in the vein. It mainly
consists of two life-threatening conditions, deep venous
thrombosis (DVT), and pulmonary embolism (PE).4
VTE is estimated to occur at an incidence rate of approxi-
mately 1 to 2 per 1000 person-years, with around 60% of
all VTE cases presenting as DVTs-only and the other 40%
giving as PEs with or without DVT. Approximately 30% of
persons who experience a VTE event will experience a recur-
rence within the following 10 years.5,6
Arterial thromboembolism (ATE) is the formation of a
blood clot in an artery. ATEs, such as ischaemic stroke, tran-
sient ischemic attack, or MI, are significant causes of death
in developed countries. According to the World Health Orga-
nization (WHO), ischaemic heart disease and stroke were the
first and second leading causes of death, responsible for ap-
proximately 16% and 11% of total deaths, respectively, in up-
per-middle-income countries in 2019.7
Multiple factors cause VTE and ATE. Some of them are in-
variable (age, gender, and genetic heritage). In contrast,
others are subject to possible interventions, such as smoking
tobacco, physical inactivity, diet habits, elevated blood pres-
sure, type 2 diabetes, dyslipidaemia, oral contraceptive or
hormone therapy use, and obesity, among others.4,8
Obesity/overweight are independent risk factors for VTE
and ATE, and their prevalence has increased dramatically dur-
ing the last decades.9 According to the WHO, the worldwide
prevalence of obesity nearly tripled between 1975 and
2016. In 2016, more than 1.9 billion (39%) adults (39% of
men and 40% of women) aged 18 years and older were over-
weight. Of these, over 650 million adults, that is, 13% of the
world’s adult population (11% of men and 15% of women),
were obese.10
Body mass index (BMI), calculated as the ratio of an indi-
vidual’s weight (in kg) to his or her squared height (in meter),
is one of the most popular measures of body mass.9 For
adults, WHO define overweight as a BMI ≥ 25 kg/m2 and obe-
sity as a BMI ≥ of 30 kg/m2.10
A positive association has been found between VTE risk
and overweight and obesity risk measures, such as body
weight, BMI, waist circumference, hip circumference, and to-
tal body fat mass.11 Thus, comparing obese with non-obese
patients, Stein et al.12 found that the relative risk (RR) of both
VTE and PE is more than doubled, 2.5 [95% confidence inter-
val (CI) 2.49–2.51] and 2.21 (95% CI 2.20–2.23), respectively,
in obese subjects (Table 1) of all ages. However, obesity
was shown to have a greater impact on DVT and PE risks in
women aged 40 years or less12 before age becomes another
independent risk factor. In men and women of 40 years or
less, the RR for PE is 5.19, and the RR for DVT is 5.20 with

Table 1 Relative risks of venous thromboembolism in patients with acquired risk factors of obesity and hormonal contraceptive use (data
from references shown in table)

Acquired risk factors of VTE RR (95% CI) of (confirmed) VTE Reference

Obese vs. non-obese patients
DVT PE
12
All ages 2.50 (2.49–2.51) 2.21 (95% CI 2.20–2.23) Stein et al. (2005)
<40 years 5.20 (5.15–5.25) 5.19 (5.11–5.28)
COC users vs. non-users
13
Levonorgestrel-EE 150–30 mcg 2.92 (2.23–3.81) *Lidegaard et al. (2011)
Desogestrel-EE 150–30 mcg 6.61 (5.60–7.80)
Gestodene-EE 75–30 mcg 6.24 (5.61–6.95)
Drospirenone-EE 3 mg-30 mcg 6.37 (5.43–7.47)
14
Levonorgestrel-EE 150–30 mcg 2.95 (2.61–3.33) **Vinogradova et al. (2015)
Desogestrel-EE 150–30 mcg (1) 6.23 (5.03–7.72)
Gestodene-EE 75–30 mcg (1) 6.47 (4.98–8.39)
Drospirenone-EE 3 mg-30 mcg 6.09 (4.73–7.83)
Combined non-oral contraceptives users vs. non-users
15
Norelgestromin-EE patch 7.90 (3.54–17.65) Lidegaard et al. (2012)
Vaginal ring of etonorgestrel-EE 6.48 (4.69–8.94)
POP users vs. non-users
15
Implant of Etonorgestrel 1.40 (0.6–3.4) Lidegaard et al. (2012b)
13
Levonorgestrel IUD 0.72 (0.49–1.06) Lidegaard et al. (2011)
Norethisterone pill 0.68 (0.30–1.51)
Desogestrel pill 0.61 (0.20–1.90)
(1) Desogestrel and Gestodene were prescribed in combinations having different doses of oestrogen (20 and 30 mcg), but no associations
between VTE risk and oestrogen dose were found.
CI, confident interval; COC, combined oral contraceptives; DVT, deep venous thrombosis; EE, ethinylestradiol; IUD, intrauterine device;
PE, pulmonary embolism; RR, relative risk; VTE, venous thromboembolism.
*
Relative risk with 95% confidence intervals, adjusted for age, calendar year, and level of education.
**
Odds ratios with 95% confidence intervals, adjusted for body mass index, smoking status, alcohol consumption, ethnic group, chronic
and acute conditions, and use of other hormonal contraceptives.

ESC Heart Failure (2022)

DOI: 10.1002/ehf2.14104

Obesity and contraceptive use: impact on cardiovascular risk
the subgroup of women being exposed to an even higher RR
of 6.10 for DVT (Table 1). The increased risk of VTE in younger
obese women aged 40 years or less is relevant because this
population usually seeks contraception, an additional inde-
pendent risk factor for VTE and PE.
There are no other published data, to the best of our
knowledge, that differentiates obese women according to
their age with regard to their increased risk of VTE or PE.
For women who are overweight without being obese,
Severinsen et al.11 found out that the OR of spontaneous
VTE was 1.45, 1.81, and 2.82 among women with BMIs of
23.7–26.3, 26.4–29.9, and >29.9 showing a growing impact
of weight on VTE risk.
As for the pathophysiological underpinnings reasoning why
VTE are more altered than ATE in obese patients, impairment
of fibrinolytic activity, increased prothrombotic factors,
pro-inflammatory state, and predisposition to venous stasis
have been postulated as possible mechanisms for increased
VTE risk.16 Conversely, the loss of body weight has been shown
to reduce the concentrations of coagulation factors and plas-
minogen activator inhibitor-1 towards the normal range.16
Severely obese patients (BMI 41.7 ± 4.6 kg/m2), who
underwent bariatric surgery, improved their coagulation pro-
files after experimenting an appropriate weight loss (usually
1 year after surgery), with a clear reduction in the hypercoag-
ulable state, without any effect on the fibrinolytic function,
thus decreasing thromboembolic risk.17 For these reasons,
contraceptive counselling should be given to women after
bariatric surgery.18
In addition, it has been postulated that low-grade inflam-
mation in obesity may be a shared pathway between MI
and VTE risks. Horvei et al.1 found that high levels of
C-reactive protein (CRP ≥ 3 mg/L vs. <1 mg/L) were
associated with increased risks of MI and VTE in women
and that the incidence rates of VTE increased with combined
higher BMI and CRP. The same study suggests that the
inflammation marker ‘CRP’ partly mediates the association
between obesity and MI and VTE.
Finally, it should be noted that pregnancy and puerperium
are well-established risk factors for VTE in both obese and
non-obese women, as discussed in the following.
In summary, overweight/obesity is an independent risk
factor for thromboembolic events. In women aged 40 years
or less, the risk of DVT increases 6.1 times compared with
non-obese women of the same age group.
Contraceptive use: a well-known risk
factor for venous and arterial
thromboembolic events
Drug-induced thrombosis can be a transient or persistent car-
diovascular risk factor depending on the duration of the drug
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3
therapy. Combined hormonal contraception products are
among the most relevant causes of continuous increased
thrombotic risk in young women.
A good number of studies have evaluated the risk of VTE
and ATE depending on the type of contraceptive used.
Lidegaard et al.,13 in a cohort study using national historical
registries from Denmark, assessed the risk of VTE from the
use of combined oral contraceptives (COCs) according to pro-
gestogen type and oestrogen dose. These authors concluded
that compared with non-users of COCs, current users of oral
contraceptives with levonorgestrel had a three-fold increased
risk of VTE (confirmed cases by anticoagulation prescrip-
tions), and those using oral contraceptives with desogestrel,
gestodene, drospirenone, or cyproterone had a six-fold to
seven-fold increased risk (Table 1). Similar results for VTE risk
(confirmed cases by anticoagulation prescriptions) were ob-
tained by Vinogradova et al.14 using data based on national
population and prescribing practices in the UK (Table 1). Re-
garding the RR of VTE in current users of combined
non-oral hormonal contraception, Lidegaard et al.15 found
that compared with non-users, the RR of confirmed VTE in
users of transdermal combined contraceptive patches was
7.9 (95% CI 3.5 to 17.7) and of the vaginal ring was 6.5 (4.7
to 8.9) (Table 1).
Progestin-only products (POPs), such as low dose
norethisterone pills, desogestrel only pills, or hormone-
releasing intrauterine devices (IUD), are not associated to
an increased risk of VTE13 (Table 1). With the levonorges-
trel-containing IUD’s use, an increased VTE risk was not found
either by van Hylckama Vlieg and Middeldorp’s studies.19
The use of COCs also increases the risk of ATE. Lidegaard
et al.,20 in a 15 year Danish historical cohort study, evaluated
the risks of thrombotic stroke and MI associated with the use
of various types of hormonal contraception, according to
oestrogen dose, progestin type, and route of administration.
The estimated RRs of thrombotic stroke and MI among users
of COCs containing ethinylestradiol at 30 to 40 μg did not dif-
fer significantly according to the type of progestin, ranging
from 1.40 to 2.20 for stroke and from 1.33 to 2.28 for MI.
For women who used a reduced dose of ethinylestradiol
(20 μg), as compared with non-users, the RRs of thrombotic
stroke and MI with desogestrel were 1.53 and 1.55, respec-
tively. For women using drospirenone with ethinylestradiol
at a dose of 20 μg, the RR of thrombotic stroke was lower
than 1.00, with no MI. Authors concluded that, although
the absolute risks of thrombotic stroke and MI associated
with the use of COCs were low, the risk increased by a factor
of 0.9 to 1.7 with COCs including ethinylestradiol at a dose of
20 μg and by a factor of 1.3 to 2.3 with those including
ethinylestradiol at an amount of 30 to 40 μg, with relatively
small differences in risk according to progestin type.20
Concerning POPs, neither the levonorgestrel-releasing IUD
nor the subcutaneous implants significantly increased the risk
of thrombotic stroke or MI in the study performed by
ESC Heart Failure (2022)
DOI: 10.1002/ehf2.14104

4 G.M.C. Rosano et al.
Lidegaard et al.20 In a systematic review and meta-analysis
conducted by Glisic et al.21 to determine the impact of POPs
use on cardiometabolic outcomes, including VTE, myocardial
infarction, stroke, hypertension, and diabetes, it was found
that the adjusted RRs for VTE, MI, and stroke for oral POPs
users versus non-users were 1.06, 0.98, and 1.02, respec-
tively. Stratified analysis by route of administration showed
that injectable POP depot medroxyprogesterone (DMPA)
had an increased risk of VTE of 2.62, while no risk was asso-
ciated with oral POPs: 1.06. These results suggest that oral
POPs use is not associated with an increased risk of develop-
ing cardiometabolic outcomes.21
A new progestin-only pill containing drospirenone at a dos-
age of 4 mg in a regimen 24/4 has been recently approved by
the US FDA and all European regulatory agencies. During its
clinical development programme, no cases of VTE or ATE
were reported, although among the 2500 patients studied,
41.9% in a US study and 16.6% in European studies had at
least one risk factor for VTE or ATE.22 These results support
the evidence that oral POPs are not associated with an in-
creased risk of ATE and VTE.
Several hypotheses have been considered concerning
mechanisms underlying the increased risk of thromboembolic
events in young women using COCs. Elevated oxidative stress
(blood hydroperoxides) was found in 77.0% of COC users vs.
1.6% only in non-COC users. High CRP levels (≥2.0 mg/L, con-
sidered risky for cardiovascular diseases) were found in
41.0% of COC users vs. 9.5% only in non-COC users.23 These
results add to the evidence that COC use alters oxidative ho-
meostasis and modifies the low-grade inflammatory status in
young women.23 In addition, the use of COCs is associated
with changes in the levels of coagulation factor, leading to a
predisposition to venous thrombosis. In this regard, patients
taking COCs have higher levels of fibrinogen, factor VII, and
factor X, in addition to increased resistance to the natural an-
ticoagulant activity of activated protein C (APC).19,24
On the contrary, publications do not suggest an increase in
risk for VTE and ATE for POPs users with a possible exception
for injectable DMPA.2,19
Finally, it should be noted that, regarding estradiol
valerate (E2V) and dienogest, few studies measured the in-
creased risk of COCs that use E2V instead of ethinylestradiol
in the general population (obese and non-obese). The
International Active Surveillance study ‘Safety of Contracep-
tives: Role of Estrogens’ (INAS-SCORE)25 concluded that the
combination of E2V with dienogest was associated with sim-
ilar or even lower cardiovascular risk compared with other
COC and levonorgestrel containing COCs. An Italian study26
showed E2V/dienogest and ethinylestradiol/levonorgestrel
contraceptives to induce a similar VTE risk, that is, 3 times
higher than non-users of hormonal contraception. Thus,
E2V may continue to negatively impact on the risk of VTE,
and this should be taken into account at the time of
prescription.
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To our knowledge, there are no published data to evaluate
if natural estradiol in COCs exposes obese patients to a differ-
ent risk than non-obese patients or to ethinylestradiol in COC
in obese patients. Data so far available suggest that natural
estradiol combination OC exposes patients to similar vascular
risks as levonorgestrel combined to ethinylestradiol.
Regarding ethinylestradiol dose and VTE, there are no data
so far available on the distinctive impact of ethinylestradiol
dose on DVT in obese and non-obese women. A study13
showed a trend to lower DVT risks with lower EE doses in
the general population. Specifically, this study found that
the oral contraceptives with desogestrel or gestodene and
20 μg ethinylestradiol implied a relative risk of venous throm-
boembolism that were 23% and 17% lower than the same
progestogens with 30 μg ethinylestradiol.
In summary, COCs use increases the risk of VTE and ATE as
compared with non-use. The procoagulant state induced by
COCs, oxidative stress, and a pro-inflammatory state contrib-
ute to the COCs-mediated predisposition to VTE and ATE.
POPs do not increase VTE and ATE risks, with some remaining
doubts with injectable DMPA.
Contraceptive use in obese women
potentiates thromboembolic risk
The combination of COCs use and overweight/obesity in-
creases the risk of thromboembolic events in women of re-
productive age.
Nightingale et al.27 conducted a meta-analysis to evaluate
the effects of age, BMI, smoking, and general health on VTE
risk in COCs users. The incidence rate of idiopathic VTE
among COC users was 39.4 per 100 000 exposed woman-
years. Apart from age, smoking, or general ill health, a rele-
vant factor identified as being significantly associated with id-
iopathic VTE in women using COCs was BMI of ≥25 kg/m2
that showed an odds ratio (OR) of 1.4 (Table 2). Interestingly,
in this study, the increase in the OR is associated to increases
in BMI. Thus, COC users with a BMI of (30 < 34.9) had an OR
of 1.8 and those with a BMI ≥ 35 kg/m2 had an OR of 3.1,
when compared with COC users with a BMI of 20–24.9
(Table 2). This study supports the hypothesis that obesity is
a causal factor of VTE in COC users.27
An increased risk for VTE was also found by Abdollahi
et al.28 in women presenting both risks, obesity and COCs
use. The evaluation of the combined effect of obesity and
COCs among women aged 15–45 revealed that COCs further
increased the impact of obesity on the risk of VTE, leading to
a 10-fold increased risk among women with a BMI greater
than 25 kg/m2 who used oral contraceptives (Table 2).28
Similar results were obtained by Pomp et al.29 in a large
population-based case–control study. The authors confirmed
that overweight (25 ≤ BMI < 30) and obesity
ESC Heart Failure (2022)
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Obesity and contraceptive use: impact on cardiovascular risk
Table 2 Synergistic effect of body mass index and oral
contraceptive use on the risk of venous thrombosis (data from
references shown in table)
OR (95% CI) of
2
BMI (kg/m ) (confirmed) VTE Reference
Oral contraceptive users who were overweight/obese vs.
non-users of oral contraceptives of normal weight
2
(BMI <25 kg/m )
25 to ≤30 1.4 (1.0–2.0) Nightingale et al.
30 to <35 1.8 (1.1–2.9) (2000)27
>35 3.1 (1.6–5.8)
>25 to <30 10.2 (3.8–27.3) Abdollahi et al.
28
>30 9.8 (3.0–31.8) (2003)
>25 to <30 11.63 (7.46–18.14) Pomp et al.
29
>30 23.78 (13.35–42.34) (2007)
BMI, body mass index; CI, confident interval; OR, odds ratio; VTE,
venous thromboembolism.
(30 ≤ BMI < 40) increase the risk of VTE 1.7-fold (OR adjusted
by age and sex) and 2.4-fold, respectively. However, when
overweight and obesity are associated with COC use, the au-
thors found that in women using COCs with overweight
(25 ≤ BMI < 30), the VTE risk increased 12-fold (OR 11.63)
and if COCs use associates with obesity (30 ≤ BMI < 40)
the VTE risk increased 24-fold (OR 23.78) if compared with
non-overweight, non-COCs users (Table 2).
The risk of ATE, such as MI and stroke, has also been
assessed in obese women using COCs. In a review by Horton
et al.,30 the authors found limited evidence concerning the
increased risk of MI and stroke in obese women using COCs.
Data were non-conclusive as compared with normal-weight
non-COCs users. On the contrary, for VTE, obese COC users
consistently had a risk of 5 to 8 times that of obese
non-users and approximately 10 times that of non-obese
non-users.30
Regarding mechanisms involved in the increased risk of
VTE in obese women using COCs, the inflammation marker
CRP was associated with BMI and COC use, among others.3
For example, in young women, a one standard deviation in-
crease in BMI was associated with a 0.37 standard deviation
increase in log (CRP), provided other variables are held
constant. COC use is associated with a 0.23 standard devia-
tion increase in log (CRP), whereas POP use is associated with
a 0.04 decrease in log (CRP).3 The combination of obesity and
COCs use appears to potentiate the pro-inflammatory state in
young women and trigger the cardiovascular risk increase. In
contrast, POPs use does not add cardiovascular risk to obese
women.
In summary, in women who combine both obesity and
COCs use, data from the literature indicate that cardiovascu-
lar risks, mainly VTE risks, increase between 12 and 24 times
compared with non-obese non-COC users. The synergistic
effect of obesity and COCs on DVT risk must be considered
when prescribing hormonal contraception. POPs are a safer
alternative to COCs in patients with overweight or with
obesity.
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5
Conclusions and recommendations
The risk of VTE and PE increases progressively with BMI, and
in obese women, it is more than double that of non-obese
subjects. Overweight/obesity has the most substantial impact
on women under 40 years when RR is 5 times higher than
non-obese subjects. Hypercoagulability, hypofibrinolysis, and
a pro-inflammatory state seem to be underlying mechanisms
involved in the increased risk of thromboembolic events in
obese women.1,9,16
Reproductive-aged women who underwent bariatric sur-
gery should avoid pregnancy for 12–24 months because of
their weight loss.18 A possibly decreased efficacy of contra-
ceptive products due to surgical procedures has been postu-
lated in this group. However, the United Kingdom Medical El-
igibility Criteria (UKMEC) provides grade 1 (a condition for
which there is no restriction for the use of the method) to
POPs in women with history of bariatric surgery with
BMI ≥ 35 kg/m2, while CHCs are not recommended.31
The RR of VTE comparing COCs users with non-users are
between 3 and 7 times higher in users vs non COCs users.13,14
On the contrary, POPs, such as low dose norethisterone pills,
desogestrel only pills, or hormone-releasing IUD are not asso-
ciated with an increased risk of VTE,13,19 while the
drospirenone only pill did not report any case of VTE or ATE
along with its clinical development programme.22 There is
limited evidence that injectable DMPA might increase the risk
of VTE.2,19
Also, thrombophilic states may have an impact on the em-
bolic events in obese women under contraception although
no data on this specific population are available to our knowl-
edge. Family history of VTE, thrombophilia, age, and obesity
must be taken into consideration at the time of prescribing
hormonal contraception.
Of note, the absolute risks of thrombotic stroke and MI as-
sociated with the use of COCs are low, although they seem to
be ethinylestradiol dose-dependent.20
In the case of COCs use in obese women, the thromboem-
bolic risk, mainly of VTE, is potentiated, ranging between 12
and 24 times if compared with the risk in non-obese, non-
users of COCs.24,25
Given that VTE risks tend to associate in the same subject
and that overweight/obesity can be associated with cigarette
smoking, arterial hypertension, and age, it is crucial to assess
the consolidated thrombotic risk resulting from the presence
of each VTE risk if present in the same subject.
The recommendation is to exercise caution with the use of
COCs in patients with overweight and obesity, choosing the
safest alternatives when prescribing hormonal contraception
due to the rising global prevalence of obesity.
Currently, obesity in combination with a sedentary lifestyle
deserves special consideration when prescribing hormonal
contraception due to excessive VTE risk.27
ESC Heart Failure (2022)
DOI: 10.1002/ehf2.14104
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6 G.M.C. Rosano et al.

Recommendations from the WHO, the Center for Disease
Control (CDC), and the United Kingdom Medical Eligibility
Criteria (UKMEC) provide grade 1 (a condition for which
there is no restriction for the use of the method) to all
POPs, including pills, IUDs, or implants for women with
BMI ≥ 30 kg/m2.31–33 In addition, the WHO, CDC, and the
UKMEC provide grade 2 recommendations for progestogen-
only pills and progestogen-only implants when multiple risk
factors for cardiovascular diseases, such as smoking, diabe-
tes, hypertension, obesity, and dyslipidaemias coexist.31–33
POPs should be considered a safer alternative than COCs in
obese women and in women combining several thromboem-
bolic risks who are seeking hormonal contraception.
Conflict of interest
Giuseppe M. C. Rosano, Maria Angeles Rodriguez-Martinez,
Ilaria Spoletini, and Pedro Antonio Regidor declare that they
have no conflict of interest.

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